Understanding the LEEP Procedure

The Loop Electrosurgical Excision Procedure (LEEP) is one of the most common and effective treatments for high-grade cervical dysplasia (CIN 2 or CIN 3). The procedure uses a thin, low-voltage electrified wire loop to cut away abnormal tissue from the cervix, simultaneously removing the precancerous cells and cauterizing the blood vessels to minimize bleeding.

When is LEEP Recommended?

LEEP is typically recommended when a colposcopy and subsequent biopsy confirm the presence of moderate to severe dysplasia. The goal is to completely excise the transformation zone—the area of the cervix most susceptible to HPV infection and where most abnormalities develop—preventing progression to cervical cancer.

Effectiveness and Dual Purpose

LEEP serves a dual clinical purpose: it is both therapeutic and diagnostic. Therapeutically, it is highly effective, successfully removing the dysplasia in 85% to 90% of cases. Diagnostically, the excised tissue is sent to a pathology lab to ensure that the margins of the tissue are clear of abnormal cells (indicating complete removal) and to confirm that no invasive cancer was hidden within the lesion.

What to Expect During and After the Procedure

The procedure is usually performed in an outpatient clinic under local anesthesia. It takes only a few minutes. Post-procedure recovery typically involves:

• Mild cramping for a few days, similar to a menstrual period.
• A watery, dark, or slightly bloody discharge for up to 3 to 4 weeks as the cervix heals.
• Pelvic rest (avoiding tampons, douching, and penetrative intercourse) for 4 to 6 weeks to prevent infection and allow the tissue to heal completely.

Impact on Fertility and Pregnancy

A common concern among patients is the impact of LEEP on future pregnancies. While LEEP is generally safe, removing tissue from the cervix can slightly alter its structural integrity. In some cases, this may lead to cervical incompetence or a slightly increased risk of preterm birth in future pregnancies. However, for most individuals, the procedure does not significantly impact fertility or the ability to carry a pregnancy to term. These risks must be weighed against the significant risk of developing cervical cancer if the high-grade dysplasia is left untreated.

The loop electrosurgical excision procedure (LEEP) is one of the most commonly used approaches to treat high grade cervical dysplasia (CIN II/III, HGSIL) and early stage cervical cancer discovered on colposcopic examination. In the UK, it is known as large loop excision of the transformation zone (LLETZ). It is considered a type of conization. It has been in use since the 1970s, after its invention by Dr.

Sheldon Weinstein. LEEP has many advantages including low cost and a high success rate. The procedure can be done in an office setting and usually only requires a local anesthetic, though sometimes IV sedation or a general anesthetic is used. Disadvantages include reports of decreased sexual satisfaction and potential for preterm labor, though a meta-analysis published in 2014 suggested that in patients with existing CIN lesions as opposed to controls, the risk is not more than their baseline risk.

Approximately 500,000 LEEP procedures are performed in the U.S. annually. When performing a LEEP, the physician uses a wire loop through which an electric current is passed at variable power settings. Various shapes and sizes of loop can be used depending on the size and orientation of the lesion. The cervical transformation zone and lesion are excised to an adequate depth, which in most cases is at least 8 mm, and extending 4 to 5 mm beyond the lesion.

A second pass with a more narrow loop can also be done to obtain an endocervical specimen for further histologic evaluation. The LEEP technique results in some thermal artifact in all specimens obtained due to the use of electricity which simultaneously cuts and cauterizes the lesion, but this does not generally interfere with pathological interpretation provided depth is not exceeded.

The thermal artifact can be a function of depth and time. Complications are less frequent in comparison to a cold-knife conization but can include infection and hemorrhage. LEEP effectively reduces the risk of cancer developing or spreading but it causes an increased risk of premature birth in future pregnancies. Following LEEP there is a 10% chance of cancer recurrence and 11% chance of preterm birth.

This perspective carries significant implications when it comes to pregnancy timing and decision making in women of child bearing age who have cervical dysplasia and would like to decide whether they should have the lesions removed before or after pregnancy. As pregnancy is generally understood to be an immune suppressed state, the viral mediated character of cervical lesions might also inform revisions to treatment recommendations in such instances.

Some women report a small decrease in sexual arousal and satisfaction following LEEP but there is a lack of high quality research showing how LEEP affects sexual function. Cervicectomy Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer. More specifically, CIN refers to the potentially precancerous transformation of cells of the cervix.

CIN most commonly occurs at the squamocolumnar junction of the cervix, a transitional area between the squamous epithelium of the vagina and the columnar epithelium of the endocervix. It can also occur in vaginal walls and vulvar epithelium. CIN is graded on a 1–3 scale, with 3 being the most abnormal (see classification section below). Human papillomavirus (HPV) infection is necessary for the development of CIN, but not all with this infection develop cervical cancer.

Many women with HPV infection never develop CIN or cervical cancer. Typically, HPV resolves on its own. However, those with an HPV infection that lasts more than one or two years have a higher risk of developing a higher grade of CIN. Like other intraepithelial neoplasias, CIN is not cancer and is usually curable. Most cases of CIN either remain stable or are eliminated by the person's immune system without need for intervention.

However, a small percentage of cases progress to cervical cancer, typically cervical squamous cell carcinoma (SCC), if left untreated. There are no specific symptoms of CIN alone. Generally, signs and symptoms of cervical cancer include: abnormal or post-menopausal bleeding abnormal discharge changes in bladder or bowel function pelvic pain on examination abnormal appearance or palpation of the cervix. HPV infection of the vulva and vagina can cause genital warts or be asymptomatic.

The cause of CIN is chronic infection of the cervix with HPV, especially infection with high-risk HPV types 16 or 18. It is thought that the high-risk HPV infections can inactivate tumor suppressor genes such as the p53 gene and the RB gene, thus allowing the infected cells to grow unchecked and accumulate successive mutations, eventually leading to cancer. Some groups of women are at a higher risk of developing CIN: Infection with a high-risk type of HPV, such as 16, 18, 31, or 33 Immunodeficiency (e.g., HIV infection) Poor diet Multiple sex partners Lack of condom use Cigarette smoking Additionally, several risk factors have been shown to increase an individual's likelihood of developing CIN 3/carcinoma in situ (see below): Women who give birth before age 17 Women who have > 1 full term pregnancies The earliest microscopic change corresponding to CIN is epithelial dysplasia, or surface lining, of the cervix, which is essentially undetectable by the woman.

The majority of these changes occur at the squamocolumnar junction, or transformation zone, an area of unstable cervical epithelium that is prone to abnormal changes. Cellular changes associated with HPV infection, such as koilocytes, are also commonly seen in CIN.

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